Triple-vessel disease of coronary artery was recognized in the examination of a 78-year-old man when hemodialysis was introduced for diabetic nephropathy. Percutaneous coronary intervention (PCI) was performed as initial treatment for the lesion of the right coronary artery. Contrast CT was performed because of persistent fever from the first day after the PCI. Since the tumor occupying the inside of the left atrium which was not found before PCI we were concerned about the failure of the hemodynamics and decided to treat it surgically. Surgery was performed with off-pump coronary artery bypass grafting, followed by left atrial mass removal surgery under cardiac arrest using cardio-pulmonary bypass. When examining the interior of the left atrium with a right lateral incision of the left atrium, the tumor was found to be on the posterior wall. This surface was smooth, and there was no endometriosis or hematoma. After incising the left atrial adventitia, old hematoma was found in the inside of the left atrium muscle layer, and it was removed as much as possible. The left atrial tumor was actually an intramural hematoma, based on image findings and macroscopic findings. Searching for the cause retrospectively, it was thought that the wire which was displaced during PCI was the cause of bleeding. We confirmed that there was no recurrence of left atrial intramural hematoma on an outpatient visit on the 113th postoperative day. We report a rare case of removing left atrial intramural hematoma under cardiac arrest which appeared after PCI.

A 72-year-old female received surgical aortic valve replacement for severe aortic stenosis in our hospital. During surgery, black pigmentation was observed in the aortic valve, aorta intima and mitral valve anterior leaflet collocated with calcification. We suspected Alkaptonuria (AKU) as a possible diagnosis for those surgical findings, past medical history and physical findings. A urine test for organic acids showed homogentisic, confirming the diagnosis of AKU. AKU is very rare genetic metabolic abnormality that occurs in about 1 in 25,000 to 100,000 people. AKU involves deficiency in the gene coding for HGA-1,2-dioxygenase, which metabolizes homogentisic acid to maleylacetoacetic acid in the tyrosine metabolic pathway. HGA accumulates in the body, causing black pigmentation in places including the aorta intima and mitral valve.

Ventricular septal rupture （VSR） is a rare but still possibly catastrophic complication of acute myocardial infarction. We report two successful cases of Impella-assisted VSR. In case 1, a 78-year-old woman was transferred to our hospital with a diagnosis of posterior VSR. After Impella insertion, cardiac output increased from 2.13 to 2.57 and the pulmonary to systemic output ratio decreased from 2.92 to 1.78. Two days after insertion of Impella, she underwent surgery. In case 2, an 89-year-old woman was transferred to our hospital with a diagnosis of anterior VSR. After Impella insertion, cardiac output increased from 2.29 to 2.85, but the pulmonary to systemic output ratio changed little from 3.79 to 3.81. Three days after insertion of Impella, she underwent surgery. Neither patient experience hemodynamic deterioration preoperatively. Postoperative echocardiography showed no residual shunt in either case. Impella for VSR seemed effective in stabilizing hemodynamics preoperatively and postoperatively.

We report a case of surgery for an infectious left subclavian artery aneurysm in a patient with metal allergy. The patient was a 41-year-old man allergic to iron, silver, manganese, and chromium. He had received a Nitinol stent in the left subclavian artery at a previous hospital. One stent had fallen out during implantation, and was put away in the terminal aorta. Ten days after the left subclavian implantation, the patient developed left shoulder pain and fever, which continued for 2 weeks. Contrastenhanced CT scan revealed a pseudoaneurysm of the left subclavian artery and abdominal aortitis. The patient underwent left subclavian artery aneurysmectomy, aorto-left subclavian artery bypass using the great saphenous vein, and removal of the stents in the left subclavian artery and abdominal aorta. The surgery was performed through a median sternotomy with cardiopulmonary support. A contrast-enhanced CT scan taken on the 12th postoperative day revealed a pseudoaneurysm of the abdominal aorta, and the patient underwent abdominal aortic artery replacement surgery on the 14th postoperative day. The patient was discharged from the hospital on the 27th day after the first surgery. The treatment of an aneurysm should be selected according to the patient’s background as well as anatomical factors.